The Biology of Orthodontic Treatment Time; Days Versus Years

Journal of Dental Health Oral Disorders & Therapy

Case Report Open Access The biology of orthodontic treatment time; days versus years

Abstract Volume 8 Issue 1 - 2017 The accurate assessment of the treatment time of an orthodontic case and its actual Anthony D Viazis,1 Evangelos Viazis,2 Tom C duration are extremely important considerations for patient acceptance of treatment as 3 well as the credibility of the health care provider and the financial health of the dental Pagonis 1Orthodontist, Private Practice, USA practice. There are multiple variables that can affect orthodontic treatment time ranging 2Private Practice, Greece from diagnosis, to treatment protocols and patient compliance. While these variables have 3Department of Restorative Dentistry and Biomaterials been widely studied there is a lack of innovation in orthodontic bracket design and its Sciences, Harvard School of Dental Medicine, USA potential impact on decreasing orthodontic treatment times. Three orthodontic patients, seen by three different clinicians present to individual offices with a pre-treatment Angle Correspondence: Tom C Pagonis, Department of Restorative classification of Class I, Class II and Class III respectively and are successfully treated Dentistry and Biomaterials Sciences, Harvard School of Dental in markedly reduced orthodontic treatment times with the new patented bracket system Medicine, 188 Longwood Avenue, Boston, MA 02115, USA, Tel of FASTBRACES® Technologies known as FASTBRACES® TURBO™. The patented 1617-432-5846, Fax 1617-432-0901, systems of FASTBRACES® Technologies facilitate the continuation of eruption while Email possibly inducing alveolar bone remodeling and development in short treatment times by moving the tooth roots toward their final naturally erupted position from the beginning Received: August 10, 2017 | Published: August 17, 2017 of treatment. This orthodontically induced eruption of teeth results in the successful completion of cases non-extraction in markedly reduced treatment times.

Keywords: orthoeruption, orthodontics, braces, alveolar bone growth, orthodontic treatment time

Introduction safely stimulate alveolar bone growth in even shorter treatment times based on the non-extraction mechanically and possibly organically Invariably every potential orthodontic patient in the consultation induced continuation of eruption by moving the roots towards their or treatment planning phase is eager to know the proposed total final position from the onset of therapy. Orthodontic treatment times duration of treatment. Motivation with compliance and commitment can now be classified in terms of days rather than years. There is a to treatment are important factors for the patient and the family along substantial body of literature that has studied variables which could with associated financial implications. The clinician must be prepared influence treatment times in both adolescents and adults. It has been to provide therapy that meets the specific lifestyle needs of patients, suggested that the key distinguishing factors between adult and especially with an increasing segment of the adult population now adolescent patients are lack of active growth, periodontal involvement 1 seeking orthodontic care. Treatment efficiency translates directly and a higher occurrence of restorative interventions.5 These traditional into practice financial health for the clinician because unanticipated variables which can affect orthodontic treatment time can generally prolonged treatment time erodes profitability. Cost efficiencies be grouped into diagnosis (including demographic observations), become even more important as the size of a practice grows and are treatment, and degree of patient compliance. an area of interest for a third party (insurance) provider.2 A system that accurately predicts orthodontic treatment time is key to both the Diagnostic variables clinician and patient because it provides a vitally important tool in practice building2 for the clinician and is directly related to greater Among this group which excludes craniofacial abnormalities, 5−9 10 overall patient satisfaction.3 Furthermore, a system of braces that generally accepted parameters include gender, age, pre- safely, predictably and effectively treats a broad cross section of treatment molar relationship, general pre-treatment assessment of 11 12,13 14,15 clinical presentations non-extraction, while substantially reducing malocclusion including overjet and overbite along with a 13,15 orthodontic treatment time presents an extremely desirable therapy variety of cephalometric features (i.e. SNA, SNB and ANB). for both clinician and patient. Treatment protocols While a review of the key factors and variables that affect A generally accepted subset of this category includes extraction orthodontic treatment time is important, this paper will also review or non-extraction therapy,5−16 technique or operator skill and 4 a new biologically-based paradigm in orthodontic diagnosis and experience,9−17 the comparison of ceramic vs. metal brackets6 along a novel biologically based orthodontic treatment approach. In with issues of orthodontic appliance breakage.6,11 addition, the authors will provide three cases of Angle’s orthodontic classifications of Class I, II and III, all treated with the patented Patient compliance systems of FASTBRACES® Technologies. This revolutionary design This category includes oral hygiene during active treatment,11−19 known as FASTBRACES® TURBO™ illustrates the potential to the number of missed appointments11 and even compliance with use

Submit Manuscript | http://medcraveonline.com J Dent Health Oral Disord Ther. 2017;8(1):432‒435. 432 ©2017 Viazis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: The biology of orthodontic treatment time; days versus years ©2017 Viazis et al. 433

of intraoral elastics.11−20 Taken together the majority of studies show time and present both the most accurate and if possible, the shortest conflicting results particularly when examining certain variables in orthodontic time with great attention to safety, patient comfort, and the Diagnosis and Treatment categories. Specifically, there appears clinical efficacy. While a wide range of variables potentially affecting to be disagreement or lack of consensus on whether treatment time orthodontic treatment time are widely cited in the literature there is is affected when examining both pre-treatment malocclusion5−8 and great controversy surrounding the scientific basis of outdated yet molar relationships.5−11 Interestingly enough the majority of studies remarkably enduring diagnostic terminology - particularly Angle’s indicate that extraction therapy may increase treatment time when classification which dates back to 21 1899. This is coupled with a compared to non-extraction therapy.5−11 Factors such as gender, substantial gap in knowledge and understanding of biologically the choice of ceramic vs. metal brackets and facial pattern had no based orthodontic diagnostic terms, the clinical recommendation of significant influence on orthodontic treatment time particularly for extraction therapy that is largely based upon outdated concepts which the adult. What seems to be consistent as it relates to affecting and maintain that alveolar bone has little or no capacity to grow22 and the lengthening treatment time is in the Patient Compliance category and lack of innovation in bracket design. Even with the introduction of includes the above referenced factors of oral hygiene, the number of flexible nickel-titanium orthodontic wires, clinicians have not evolved missed appointments, compliance with use of intraoral elastics and from a segmented approach to therapy that fundamentally contemplates incidence of broken appliances? the use of a rounds wire to move clinical crowns at the beginning of treatment which is followed by the addition of successive rectangular Report of cases wires to move the roots of teeth. In aggregate, the combination of Three adult patients, seen by three different providers presented diagnostic terms that lack scientific validity, stagnation in bracket for orthodontic treatment with Angle classifications of Class I, Class innovation and a seemingly unwavering adherence to the static nature II and Class III respectively. Full maxillary and mandibular fixed of alveolar bone drives the clinician to extraction therapy or non- appliances followed by retainers were applied for all three cases. extraction from uncontrolled tipping of teeth with round wires. The Treatment time for the three patients presenting with Class I, Class use of outdated orthodontic mechanics clinically delivers excessive II and Class III malocclusions took 96 days, 72 days and 117 days orthodontic mechanical forces with a staged multiple wire approach respectively (Figures 1−3). of moving crowns then roots through, rather than with alveolar bone. The cumulative effect is a greater duration of treatment with increased mechanical forces. Therefore, it is the opinion of the authors that these practices represent some of the most important reasons why orthodontic treatment times have not been decreased. It is ironic that many diagnostic, treatment and patient compliance variables have been studied without contemplating the impact of improving bracket Figure 1 Before, during, and after frontal Photographs of angle class I malocclusion treated in 96 days (Courtesy of Dr. Patrick Assal, Lausanne, design and biomechanics. One need not look further than the lighter Switzerland). force, the capacity to stimulate remodeling and growth of alveolar bone along with the associated treatment time of natural eruption in order to develop advanced orthodontic technology systems. These new patented systems of braces known as FASTBRACES® Technologies are designed to facilitate the continuation of eruption while inducing alveolar bone remodeling and development in short Figure 2 Before, during, and after frontal photographs of Angle class II treatment times by moving the tooth roots toward their final naturally malocclusion treated in 72 days (Courtesy of Dr. Melissa Goddard, Liverpool, United Kingdom). erupted position from the beginning of treatment. This orthodontically induced eruption of teeth results in the successful completion of cases non-extraction. Viazis et al.4 introduced the biologically based orthodontic diagnostic terms of Orthodontosis and Orthodontitis.4 Orthodontosis Figure 3 Before, during, and after frontal photographs ofAngle class III is defined as the non-inflammatory deficiency of alveolar bonein malocclusion treated in 117 days (Courtesy of Dr. Stephan Van Vuuren, London, the horizontal dimension caused by the displaced root(s) of the United Kingdom). tooth, typically palatally or lingually. Orthodontitis is defined as associated excess soft tissue manifestation and chronic inflammation. Discussion In effect the hard tissue bony hypoplasia (Orthodontosis) and soft The extraordinary reductions of treatment times for Class I, II tissue manifestation (Orthodontitis) associated with malpositioned and III cases are clearly demonstrated in these three case reports. roots represent unfinished eruption. Based upon these definitions, The question the clinicians should be asking is how orthodontic orthodontic treatment should be directed towards mimicking and treatment times now can be addressed in terms of days when nearly continuing the light forces of natural eruption possibly stimulating all comprehensive orthodontic case treatment times are addressed bone remodeling around displaced roots thereby eliminating the in terms of years. While esthetic and functional concerns represent need for extraction therapy. Furthermore, this mechanically assisted the key elements for patients seeking orthodontic treatment, the continuation of eruption has been defined as Orthoeruption in the 4 proposed treatment time in many cases represents the central cohesive literature and allows for the up-righting of displaced roots into a element of a patient accepting a proposed orthodontic treatment plan. straight position as if the teeth erupted in that position. Therefore, In addition, it is incumbent upon the clinician to assimilate possible Orthoeruption results in the alveolar bone remodeling and restoration individual patient variables that could potentially affect treatment of the dental arch to its appropriate natural size and shape. Accordingly,

Citation: Viazis AD, Viazis E, Pagonis TC. The biology of orthodontic treatment time; days versus years. J Dent Health Oral Disord Ther. 2017;8(1):432‒435. DOI: 10.15406/jdhodt.2017.08.00268 Copyright: The biology of orthodontic treatment time; days versus years ©2017 Viazis et al. 434

non-extraction therapy is almost always achieved through this of inflammation, edema, pressure and ischemia. Pain typically starts alveolar bone growth as the alveolar bone reacts to a tooth erupting in within 4 hours of traditional orthodontic activation increasing over its correct place in the arch. the next 24 hours. Inflammation on the other hand subsides in about six weeks and tissues are restored accordingly. Therefore, traditional The three cases presented in this paper along with other published orthodontic treatment initiates excessive and unevenly distributed literature23−37 illustrate the potential to stimulate remodeling and mechanical forces which then create hyalinization of the PDL thereby growth of alveolar bone with the patented orthodontic systems stopping active tooth movement while generating patient pain.29 The of FASTBRACES® Technologies almost irrespective of the type limiting factor in decreasing orthodontic treatment time appears to be of pre-treatment dental malocclusion. The authors believe these hyalinization induced by the clinician. The PDL may be restored but new technology systems of braces including the newly introduced the root apex is permanently resorbed–accepting it as a consequence FASTBRACES® TURBO™ facilitate the continuation of eruption of traditional orthodontic tooth movement. This unfavorable sequence while inducing alveolar bone remodeling and development in short of biological events causes a significant treatment time gap until treatment times by moving the tooth roots toward their final naturally tissues are restored from hyalinization only to have them damaged erupted position from the beginning of treatment design. Theoretically again with a subsequent orthodontic treatment visit. This creates a and when compared to natural continuous eruption, the technology cycle of inefficient and prolonged treatment, patient discomfort and sustains Orthoeruption which induces alveolar bone formation possible root resorption. thereby providing space. This self-generating process of alveolar bone could closely mimic natural eruption by organically induced alveolar As shown in other published literature,23−29 orthodontic therapy bone growth and remodeling. This orthodontically induced eruption with the patented systems of FASTBRACES® Technologies can of teeth results in the successful completion of cases non-extraction. safely, effectively and efficiently complete treatment non-extraction Our theory requires additional study both at the clinical and biological with little patient discomfort, and with little to no apical resorption level. For example, while the authors believe that Orthoeruption all among a diverse set of clinical presentations. Therefore, the is said to be similar to or the continuation of natural eruption we orthodontic or tooth movement process, the lack of root damage, the realize that natural eruption takes place with a developing root and lack of patient pain and a completion time of 120 days approximates an incompletely formed periodontal ligament while Orthoeruption natural eruption. This lack of patient pain coupled with a duration takes place with a fully formed root and periodontal ligament. Why of treatment equivalent to natural continuous eruption and a natural then are there reduced treatment times with the patented systems looking mouth upon treatment completion strongly suggests a new of FASTBRACES® Technologies and how can a fully formed root paradigm of orthodontic tooth movement that is biologically based continue to erupt or exhibit Orthoeruption with reduced treatment and similar to natural continuous eruption. Furthermore, the absence times which approximates the time frame of natural continuous of pain in both natural eruption and Orthoeruption strongly suggests eruption? All cases presented herein finished within 120 days which little to no inflammation or little to no hyalinization. The authors is typically the time frame of the continuous eruption of teeth or believe that shortened treatment times with the patented systems of from the moment the clinical crown appears in the oral cavity until FASTBRACES® Technologies are strongly correlated with semi- it reaches occlusal contact with the dentition of the opposing arch. It hyalinization to no hyalinization. Additional research is needed to thus begs the question that Orthoeruption by continuing the motion study possible shortened times of hyalinization or even unremarkable of the tooth by utilizing the light forces of the patented systems of changes towards hyalinization with the lighter forces of the patented FASTBRACES® Technologies happens within the normal biological systems of FASTBRACES® Technologies as a possible reason for boundaries of the human body. Further speculation may lead the markedly decreased orthodontic treatment time. Another area of clinician to surmise that the patient “feel” of normality similar to that research that may provide additional clues of the underlining biology of natural eruption (with the exception of an exfoliating deciduous of decreasing orthodontic treatment times would be to compare the tooth for example) represents the ideal force that fools the body by complex interactions and cascade of reactions between alveolar continuing the eruption during treatment. bone remodeling associated with orthodontic tooth movement and the biology of fracture healing whether alveolar or other. This might One area to explore is hyalinization of the periodontal ligament suggest a way to minimize the impact of our orthodontic interventions (PDL) during orthodontic tooth movement. Hyalinization so as to facilitate and promote alveolar bone remodeling and growth fundamentally represents the localized degenerative change in the thereby decreasing orthodontic treatment time. ultrastructure of the periodontal ligament brought on by pressure during orthodontic tooth movement. This is based on the well- Conclusion established pressure/tension theory of orthodontic tooth movement which even recent literature suggests that as a theory it is not The three case reports covered in this paper illustrate the potential completely understood.28 Specifically, this localized cell death or to stimulate remodeling and growth of alveolar bone with shortened hyalinization on the pressure side of orthodontic tooth movement treatment times by utilizing the patented orthodontic systems of against the periodontal ligament is an undesirable effect characterized FASTBRACES® Technologies which is based on the non-extraction by disturbances in blood flow and changes in the PDL collagenous mechanically aided continuation of eruption by moving the roots matrix caused by the tipping forces of round wires that concentrate toward their final position from the onset of therapy. The shortened around the cemeto-enamel-junction and the root apex. In the presence orthodontic treatment times are consistent across a diverse cross of hyalinization, orthodontic tooth movement cannot occur until the section of pre-treatment malocclusions with treatment performed hyalinized tissue is resorbed and replaced by healthy tissue again. by three different clinicians. The authors suggest that among This then allows the underlining resorption of adjacent alveolar bone variables used to access duration of orthodontic treatment there is which represents tooth movement. The hallmark clinical presentation a considerable gap of knowledge in biologically based orthodontic of hyalinization is periodontal pain which is caused by the combination diagnosis, associated treatment planning and most importantly,

a lack of innovation in bracket design. The introduction of the in a graduate orthodontics clinic. Am J Orthod Dentofacial Orthop. patented systems of FASTBRACES® Technologies including the 2008;133(1):9.e1−9.e13. newly introduced FASTBRACES® TURBO™ represent novel and 12. Auconi P, Scazzocchio M, Cozza P, et al. Prediction of Class III innovative systems which facilitate what the authors believe to be the treatment outcomes through orthodontic data mining. Eur J Orthod. continuation of natural eruption or Orthoeruption inducing alveolar 2015;37(3):257−267. bone remodeling and development by moving the tooth roots toward 13. Barroso MC, Silva NC, Quintão CC, et al. The ability of orthodontist and their final naturally erupted position from the beginning of treatment. laypeople to discriminate stepwise advancements in Class II retrognathic This orthodontically induced eruption of teeth results in the successful mandible. Prog Orthod. 2012;13(2):141−147. completion of cases non-extraction. Similarities between the processes of natural continuous eruption and Orthoeruption suggest a 14. Dimberg L, Lennartsson B, Söderfeldt B, et al. Malocclusions in lack of inflammation and therefore a diminished degree of or absence children at 3 and 7 years of age: a longitudinal study. Eur J Orthod. 2013;35(1):131−137. of hyalinization as the possible key to reduced orthodontic treatment times with the patented systems of FASTBRACES® Technologies. 15. Jeremiah HG, Cousley RR, Newton T, et al. Treatment time ad oclusal outcome of orthognathic therapy in the east of England region. J Orthod. Funding 2012;39(3):206−211. None. 16. Fisher MA, Wenger RM, Hans MG. Pretreatment characteristics associated with orthodontic treatment duration. Am J Orthod Dentofacial Acknowledgements Orthop. 2010;137(2):178−186. 17. Popowich K, Flores-Mir C, Nebbe B, et al. Comparison of Class I and The authors wish to acknowledge the contribution of Drs. Patrick Class II treatment duration among three di erent orthodontic practices. Assal, Melissa Goddard and Stephan Van Vuuren who provided the Semin Orthod. 2006;12(1):52−59. cases referenced in this paper. 18. Hend Salah Hafez, Essam Mohamed NS, Kamel Eid FH, et al. Cytoxicity, Conflicts of interest genotoxicity, and metal release in patients with fixed orthodontic appliances: A longitudinal in-vivo study. Am J Orthod Dentofac Orthop. Author declares that there are no conflicts of interest. 2011;140(3):298−308. References 19. Antonio Jose Ortiz, Esther Fernández, Vicente A, et al. Metallic ions released from stainless steel, nickel-free, and titanium orthodontic 1. Turbill EA, Richmond S, Wright JL. The time-factor in orthodontics: alloys: Toxicity and DNA damage. Am J Orthod Dentofac Orthop. what influences the duration of treatments in the National Health 2011;140(3):e115−e122. Service practices? Community Dentistry and Oral Epidemiology. 2001;29(1):62−72. 20. Angle EH. Classification of malocclusion. Dental Cosmos. 1899;41(3):248−264. 2. Shia GJ. Treatment overruns. J Clin Orthod. 1986;20(9):602−604. 21. Bernsteim L, Edward H. Edward H Angle versus Calvin S. Case: 3. Cunningham SJ, Hunt NP, Feinmann C. Perceptions of outcome following extraction versus nonextraction. Historical revisionism. Part II. Am J orthognathic surgery. Br J Oral Maxillofac Surg. 1996;34(3):210−213. Orthod Dentofacial Orthop. 1992;102(6):546−551. 4. Viazis AD, Viazis E, Pagonis TC. The Concept of a New Dental Disease: 22. Viazis AD, Viazis E, Pagonis TC. The Fallacy of Tongue Thrust and Non- Orthodontosis and Orthodontitis. J Dental Health Oral Disord Ther. Surgical Treatment of a Severe Anterior Open Bite. J Dental Health Oral 2014;1(5):00030. Disord Ther. 2016;4(4):00120. 5. Dyer GS, Harris EF, Vaden JL. Age effects contrasted on orthodontics 23. Viazis AD, Viazis E, Pagonis TC. Non-Surgical Orthodontic Treatment with adult treatment: Adolescents. Am J Orthod Dentofacial Orthop. of an Orthognathic Surgical Case. J Dent Health Oral Disord Ther. 1991;100(6):523−530. 2016;4(5):00128. 6. Beckwith FR, Ackerman RJ, Cobb CM, et al. An evaluation of factors 24. Viazis AD, Viazis E, Pagonis TC. Non-surgical Orthodontic Adult Molar affecting duration of orthodontic Treatment. Am J Orthod Dentofacial Crossbite Correction and Sleep Apnea. J Dent Health Oral Disord Ther. Orthop. 1999;115(4):439−447. 2016;5(5):00168. 7. Fink DF, Smith RJ. The duration of orthodontic treatment. Am J Orthod 25. Viazis AD, Thaveeprungsiporn M, Pagonis TC. Alveolar Bone Dentofacial Orthop. 1992;102(1):45−51. Remodeling and Development after Immediate Orthodontic Root Movement. J Dent Health Oral Disord Ther. 2017;6(2):00195. 8. Haralabakis NB, Tsiliagkou K. The effect of six variables and their interrelation on the duration of orthodontic treatment. Hellenic Orthod 26. Viazis AD, Viazis E, Pagonis TC. Alveolar Bone Growth with Rev. 2004;7(1):45−57. Orthoeruption. J Dent Health Oral Disord Ther. 2017;7(5):00258. 9. Skidmore KJ, Brook KJ, Thomson WM, et al. Factors in reducing 27. Melsen B. Tissue reaction to orthodontic tooth movement-a new treatment time in orthodontic patients. Am J Orthod Dentofacial Orthop. paradigm. Eur J Orthod. 2001;23(6):671−681. 2006;129(2):230−238. 28. Krishnan V, Davidovitch Z. Cellular, molecular, and tissue-level reactions 10. Mavreas D, Athanasiou AE. Factors affecting the duration of orthodontic to orthodontic force. Am J Orthod Dentofacial Orthop. 2006;129(4):469. treatment: a systematic review. Eur J Orthod. 2008;30(4):386−395. 29. Wise GE, King GJ. Mechanisms of tooth eruption and orthodontic tooth 11. Vu CQ, Roberts WE, Hartsfeld JK, et al. Treatment complexity index movement. J Dent Res. 2008;87(5):414−434. for assessing the relationship of treatment duration and outcomes

Citation: Viazis AD, Viazis E, Pagonis TC. The biology of orthodontic treatment time; days versus years. J Dent Health Oral Disord Ther. 2017;8(1):432‒435. DOI: 10.15406/jdhodt.2017.08.00268